Care of the Unconscious Patient Acute Care Day Case Studies Assessing GCS Looking after the Unconscious Patient

Assessing Consciousness Using GCS Prevention of secondary complications of Coma Safely managing comatose patients There are many ways to assess neurological status in the comatose patient. The aim of this tutorial is to make sure that the GCS is used and recorded properly and is used as part of the assessment and acute resuscitation of the patient who has decreased conscious level. By the end the students should be able to chart and record an accurate GCS in addition to realising some of the practical care of the unconscious patient.

Principles of assessing Consciousness Glasgow Coma Scale Eye Response 4 Eyes open spontaneously 3 Eyes open to verbal Command 2 Eyes open to Pain 1 No eye opening Motor Response 6 Obeys Commands 5 Localises to Pain 4 Withdraws to pain 3 Flexes to pain 2 Extension to pain 1 No Motor Response Verbal Response 5 Orientated 4 Confused 3 Inappropriate Words 2 Incomprehensible Sounds 1 No Verbal Response Go through the GCS and how it is scored. Explain how to obtain the responses with a supraclavicular stimulus and even on the face if necessary, Explain that localising is crossing midline compared to flexing

This is a typical chart for putting coma scale on. Please explain the any score less than GCS 8 is classified as Coma.

Assessing GCS Score should always be documented as the 3 components and not just a total Needs to be re-assessed regularly Make sure stimulus is applied above the clavicle when assessing – in case there is a high spinal lesion

Acute Respiratory Care Day Case 1 Acute Respiratory Care Day All 3 cases are to scored by students. 6

Case 1 30 year old Found by shopkeeper when opening up shop sleeping in shop doorway, when asked to move on seemed a bit confused, Became progressively more drowsy and refused to move from doorway so ambulance called. You are called to assess him in A&E

Case 1 (1) Click on picture to trigger video.

What are you going to do?

Assessment A B C D E ABCDE approach to be reiterated 10

Respiratory rate 20 breaths per minute Oxygen saturations 97% on air A and B Talking (confused) Respiratory rate 20 breaths per minute Oxygen saturations 97% on air Trachea central Normal Breath sounds 11

C Good Capillary return Pulse 120bpm BP 110/65 mmHg

Assess GCS (Chart on your chart) D and E Assess GCS (Chart on your chart) Nothing else found on exposure Specifically no signs of trauma Sweaty 13

Case 1 D and E Get the students to chart the GCS and swap charts with each other so that they can see whether they have charted consistently, emphasise to them the fact that the stimulus was supraclavicular so that potential spinal injury does not affect the assessment. Encourage a bit of discussion about the actual scoring and clarify the issues raised – especially that it is the best response obtained. Discuss AVPU as an alternative quick assessment in triage or an emergency. A-alert V-responds to voice P- responds to pain U-unresponsive 14

Further Investigations? Further Management? Case 1 What Now? Further examination? Further Investigations? Further Management? Sweaty Blood glucose <1 U&E otherwise normal Allow them to give sweet drink, glucose infusion or glucagon CT would probably depend on response to treatment. Ie don’t ever forget the glucose.

Case 1 Nurse calls you back to see him because she is concerned about his condition Ask them what kind of things they should be doing now? Emphasise the necessity for re-assessment and Encourage ABC again Show the video on the next slide.

Case 1 (2)

Case 1 (2nd set obs)

Case 1 What is his coma scale now? Chart his coma scale now on your paper chart What further assessment do you need to do? A – slight snoring, but has he still got protective reflexes B- SaO2 95% on air, Air entry still OK C pulse 115 Bp 140/85 What further investigations does he need? Potential causes for his acute change? Get them to discuss how they should change the emphasis their management, The idea is to get them to recognise that this is now a dynamic situation, his condition is deteriorating, they will have to consider protecting his airway now and also finding out why his condition has deteriorated. The reason is actually that he has taken a slow release insulin injection and that is now having more of an effect. His hypoglycaemia has recurred, and his conscious level has decreased. They are now dealing with an unconscious patient and need to focus on that as well as treating hypoglycaemia i.e. ABC and go on to discuss the following slides about dealing safely with a comatose patient who has no protective reflexes.

Preventing pressure sores Protecting neck and limbs from injury What Measures do you need to take to ensure safety of unconscious patient? Airway protection Positioning Preventing pressure sores Protecting neck and limbs from injury Corneal protection

Clinical Decisions in the Unconscious patient Combination of diagnostic steps and treatment decisions Pragmatic assessment of adequacy of medical support Find treatable disorder Initial care, diagnosis and treatment of reversible pathology Think about safety for transfer of patients Consent for treatment / Incapacity Forms Briefly refer to the fact that any patient who is comatose is not competent to give consent for procedures and that an incapacity certificate would be appropriate for any consent for further treatment required. I.e. surgery or invasive investigations, monitoring or ICU care or withdrawal of treatment. (obviously not appropriate in this actual case, but principles need a bit of emphasis)

Prevent complications Aspiration Pressure Sores Dehydration Malnutrition Secondary brain injury Nosocomial infections Eye and mouth care DVT/PE Rhabdomyolysis

Case 2 33 year old man, has been found at bottom of flight of stairs in his close, He has blood on the back of his head, and the ambulance crew have said that there was some blood coming from his left ear when they arrived at the scene CLICK ON PICTURE TO PLAY VIDEO Get students to score GCS before going to next slide.

Get the students to score on their sheet and compare with this

Where is the Lesion likely to be? Case 2 – Chart his GCS Where is the Lesion likely to be? Note Fixed dilated left pupil Flexing on right Localising on left The presence of a unilateral fixed dilated pupil is due to an oculomotor lesion. It can be from compression of midbrain oculomotor complex, traction of the oculomotor nerve, or pressure of nerve against the clivus. Or hernia ion of the uncal hippocampus directly compressing the third nerve at the edge of the tentorium. The next slide (on the day will be a CT of possible brain lesion)

Case 3: Presentation 18 year old 3 week history of dental abscess on left upper molar Too afraid to go to dentist so took his mother’s co-codamol tablets Fever for 1 week, Found by mother in bedroom, could not wake him up this morning, called ambulance.

Case 3: Initial Assessment: Airway Clear (how do you test for that?) No cough or gag reflex B SaO2 96% on air, Air entry both sides C P 130 Sinus rhythm Bp 85/32 Warm, vasodilated, This is the results of the ABC assessment The next slide is a video of coma score – get the students to score again on their sheets.

What is his GCS? Case 3 D and E 30 Get the students to chart on their chart what the GCS is now 30

Case 3 GCS There may be a bit of variation of scoring on this, encourage discussion. Emphasise that the score is the best obtained. Note each side is different due to localisation of lesion The last slide will be the CT showing the lesion.

What next? Any investigations?

How are you going to transport him safely to CT? Case 3: What next? Any investigations? Temp 40.5 C WCC 25 CRP 450 CT - How are you going to transport him safely to CT? Requires Intubation call anaesthetist.

Questions?